Ira Byock, MD is Director of Palliative Medicine at Dartmouth-Hitchcock Medical Center in Lebanon, New Hampshire and a Professor of Anesthesiology and Community & Family Medicine at Dartmouth Medical School.
Dr. Byock has authored numerous articles on the ethics and practice of hospice, palliative and end-of-life care. His first book, Dying Well, (1997) has become a standard in the field. His most recent book, The Four Things That Matter Most, (2004) is used as a counseling tool widely by palliative care and hospice programs, as well as within pastoral care.
Dr. Byock has been a consistent advocate for the voice and rights of dying patients and their families. He has been the recipient of the National Hospice Organization’s Person of the Year (1995), the National Coalition of Cancer Survivorship’s Natalie Davis Spingarn Writers Award (2000), the American College of CHEST Physicians Roger Bone Memorial Lecture Award (2003) and the Outstanding Colleague Award (2008) of the National Association of Catholic Chaplains.
Question: Do people have the right to choose when to die?
Ira Byock: Well, I don’t know if it is an issue of right, I think they have a right to avoid any medical care they don’t want, they may have the power to die at their own choosing, but whether it is a source of human rights, it seems like that something out of the purview of my authority, and I am not even sure it’s within the purview of the construct of social authority to grant. It seems like some things are out of our hands. So the question is do people have a right to suicide? Well, maybe at some points in time, the society recognizes such a right. We don’t when – when they are not physically ill, as an emergency physician I certainly interrupted any number of attempted suicides, with societies blessing and in fact requirement, but there maybe a time when somebody is seriously ill when we recognized their right to suicide. Whether that means that physicians are legally empowered to assist in a suicide is a different question. And that’s really a question of public policy that I think often distracts us from the real issues but --
I don’t know, they certainly have the power, I can tell you that when people tell me that they are thinking about ending their life, when they are seriously ill, I used it as a clinical opportunity to explore why they feel it that their life has lost meaning and how I can assist them in improving whatever quality of life they may have, but I – it’s not a situation where I think about instituting an emergency psychiatric hold or hospitalizing them against their will. I don’t actively act to stop people from committing suicide who are, usually who are seriously ill, as I would in other circumstances. But I do talk to them about it with – I talk to people about this issue quite frequently.
Topic: The Case of Terry Schiavo
Ira Byock: I think that Schiavo case was confusing for a lot of Americans, first and foremost it was an incredible tragedy for that young women and for her family, and you got to see families struggles play out in the most obscene public way. It was just – it was just wrenching. From an ethical perspective, I think it was pretty confusing, legally clearly her husband had the right to withdraw a medically administrated nutrition and hydration, that’s really shadowed matters of ethics and law. I have to say during that time, just coincidentally there was a bill in the New Hampshire legislature to revise our advanced directive laws in New Hampshire. And some very ardent right to life communities there tried to clarify and strengthen provisions that would require – legally require medical providers to do CPR: Cardiopulmonary Resuscitation, on everyone as they were dying, unless the person themselves, the individual themselves had signed a permission not to do CPR.
And similarly to give medically administrated nutrition and hydration to everyone as they were dying, unless the person had specifically given authority in their power of attorney document to their health agents to refuse. I was testifying that that made no sense that CPR clearly at some point makes absolutely no physiologic sense, it was never designed to restart the heart of somebody who was acknowledged to be dying. And it doesn’t work anyway. And that medically administered nutrition and hydration, not uncommonly in a far advanced diseases makes things worse, imposes suffering, and actually not uncommonly will hasten a person’s death, not help them live longer because it poisons their liver, and just they can deal, their body can’t deal with the metabolites coming to it. At the same time, there was an assisted suicide bill in Vermont, and I have known to be an opponent to legalizing physician assistant suicide, very narrowly defunct. Interestingly in the same week I was getting angry letters from people in Vermont castigating me for opposing legalizing assisted suicide, and being unwilling to write lethal prescriptions when somebody was dying.
And getting angry letters from some fringe right to life extreme groups in New Hampshire, because I was allowing innocent people to die because I refused to do CPR, and refused to give them medically administered nutrition and hydration. As widely opposed, points of US possible, the only thing that connects them is a distrust of doctors and nurses and the healthcare systems in which we work. And I think if I learned anything from Schiavo, and again during that time Pope John Paul was dying, and there was really aggressive assisted suicide, things happening as well, that we have a cultural chasm in America and have no clarity about what a healthy end-of-life experience would look like, what morally acceptable end-of-life experience would look like, but we do have a distrust of doctors in the healthcare system.
Question: Why do you oppose physician assisted suicide?
Ira Byock: I opposed the legalizing of physician assisted suicide, because I believe that it’s a further distraction from the real deficiencies and dysfunctions in our healthcare system and our medical education system, that makes dying so hard in America today. It’s not because it’s controversial really that I oppose legalizing assisted suicide, I think it wouldn’t make anything better and might well make things worse. It might make things worse because it acts as a pressure valve on society from addressing some of the woeful deficiencies, and it won’t make anything better, really, if you legalize physician assisted suicide nationwide next Monday, next Tuesday we still won’t be educating physicians, medical students in how to communicate with people, give bad news, help people through the inherently difficult time of life we call dying, we won’t be educating them any more on assessing people’s pain or treating pain.
We won’t be requiring Medicare to provide hospice like coverage earlier in the course of an illness or to pay for palliative care and home care. All of those things we won’t be staffing our nursing homes any better than we did on Monday. All of those things would be left in place, and yet all of the advocates for legalizing assisted suicide, I absolutely am confident would go away, because they don’t show up for any of the other efforts that we’re trying to do to expand education and insurance coverage and staffing and nursing homes. They are not there. They have this sort of sexy fascination with preempting death. Now I have written frankly, I have been on the con side of legalizing assisted suicide for a long time but frankly in recent years, I have written strongly asserting that in the arguments and the debate over physician assisted suicide, both sides are wrong.
The assisted suicide people are wrong, the pros are wrong because frankly it wouldn’t change anything and might actually retard real progress, and the people who oppose physician assisted suicide are wrong, because they only tell us what they are against. And the catholic church which happens to have been right on this issue all along hasn’t told us the rest of the story, and they haven’t stepped up to the plate, just to tell their congregations and parishes and dioceses to show the rest of us what enlighten care looks like. If we are supposed to provide nutrition and hydration for everyone, well then show us what that looks like in a contemporary America in a way that’s enlightened, but don’t just warehouse people or tell the government it’s our responsibility, because we don’t know. So frankly even when they have been right, the church and others have looked sanctimonious, self righteous and really stingy, frankly.
And it hasn’t helped those of us, I am not Catholic but those of us who have been opposed to legalizing physician assisted suicide for clinical and ethical and really social reasons. It hasn’t helped us make our case because by implication we sound sanctimonious, which frankly is not where we are coming from. I am a lifelong political progressive and proud to be. I don’t see legalizing assisted suicide add some extension of our personal freedoms, I think it’s a regression and apology for a failed social policy and failed healthcare policy. And unless or until we can really as a culture and society take good care of our grand parents and our parents and our brothers and sisters and our children during this time of life we call dying, we really haven’t married [phonetic] the right to even have the discussion of preempting that.
Recorded on: March 21, 2008